Swedish National Audit Office concludes: When all you have is CBT, mental health suffers

That’s the headline from one of Sweden’s largest daily newspapers for Monday, November 9th. Professor Gunnar Bohman, together with colleagues and psychotherapists, Eva Mari Eneroth Säll and Marie-Louise Ögren, were responding to a report released last week by the Swedish National Audit Office (NAO).

Back in May 2012, I wrote about Sweden’s massive investment in cognitive behavioral therapy (CBT). The idea was simple: address rising rates of disability due to mental illness by training clinicians in CBT. At the time, a mere two billion Swedish crowns had been spent.

Now, several years and nearly 7 billion Crowns later, the NAO audited the program. Briefly, it found:

The widespread adoption of the method had no effect whatsoever on the outcome of people disabled by depression and anxiety;

A significant number of people who were not disabled at the time they were treated with CBT became disabled thereby increasing the amount of time they spent on disability; and

Nearly a quarter of people treated with CBT dropped out.

The Swedish NAO concludes, “Steering towards specific treatment methods has been ineffective in achieving the objective.”

How, you might reasonably ask, could anyone think that restricting choice would improve outcomes? It was 1966, when psychologist Abraham Maslow famously observed, “I suppose it is tempting, if the only tool you have is a hammer, to treat everything as if it were a nail” (p. 15, The Psychology of Science). Still, many countries and professional organizations are charting a similar path today.

The choice is baffling, given the lack of evidence for differential efficacy among psychotherapeutic approaches. Consider a study I blogged about in April 2013. It was conducted in Sweden at 13 different public health outpatient clinics over a three year period. Consistent with 40 years of evidence, the researchers found that psychotherapy was remarkably effective regardless of the type of treatment offered!

So, what is the key to improving outcome?

As Bohman, Säll and Ögren point out in their article in Svenska Dagbladet, “offering choice…on the basis of patients’ problems, preferences and needs.”

Learn more by joining the International Center for Clinical Excellence–a free, web-based community of practitioners dedicated to improving the quality and effectiveness of clinical work. Better yet, join colleagues from around the world at our upcoming March intensive trainings in Chicago! Register soon as both the Advanced Intensive and FIT Supervision Courses are already more than half subscribed.

Comments

Thanks for the interesting blog, I hadn’t heard of feedback informed treatment.

A few questions:

If all therapeutic treatments are equally remarkably effective, firstly why don’t governments simply pay for the cheapest? And secondly, why then does CBT in this instance *not* seem remarkably effective?

Thirdly, is a drop out rate of 25% very bad, relative to most state-provided free therapy?

Fourth, to what extent should patient choice be married to evidence? If a patient wants aromatherapy, should the state provide it? Or shamanic healing? Or primal scream therapy? Does such a model not make public service funding vulnerable to whatever new therapy is being hyped in the popular press, regardless of the outcome?

Thanks for your note Jules. I hope you will join the ICCE and explore the various resources there. Many professionals from around the world are shring their experiences and knowledge about how to integrate feedback into practice. So, you asked:

–>In my country, they are paying for the cheapest. In others, leaders do not believe all treatments are equally effective. CBT was among the first to gather and report outcome data. The approach has enjoyed a privileged position ever since.

2. And secondly, why then does CBT in this instance *not* seem remarkably effective?

–>This is, as I’ve reported, the case MOST of the time. Many think it is, developers talk about it as if it is, but it’s not.

3. Thirdly, is a drop out rate of 25% very bad, relative to most state-provided free therapy?

–>Drop out rates vary widely by practitioner. The point here is that CBT was promised to improve outcomes. If we can’t get people to attend, and they are made worse, the decision to limit treatment to this single approach must be questioned. Still, in Sweden, official guidelines still recommend largely CBT-oriented approaches.

4. Fourth, to what extent should patient choice be married to evidence? If a patient wants aromatherapy, should the state provide it? Or shamanic healing? Or primal scream therapy? Does such a model not make public service funding vulnerable to whatever new therapy is being hyped in the popular press, regardless of the outcome?

–>You get the implications exactly. IF, we measured outcome, and held providers accountable for their effects, rather than the type of treatment offered, and the treatment was effective (legal, and ethical), who cares?

If the main paying role is CBT then it will attract more counsellors. The more counsellors the more the mix of ability – hence CBT gets a worse than deserved name but the research shows that good therapists get results irrespective of modality or school.
FIT sounds very similar to pluralistic practice – use the best for each individual client.
Tony – Warrington UK

I’m on a BA (Hons)degree course in Counselling and my dissertation is about the client’s freedom to chose – how do counsellors of various therapeutic models integrate an existential concept? So, I’m looking for up to date material about the subject. Maybe joining in, will help me explore more? Thanks for your time. Marlene

I’ve recently read that CBT is going to be the main, if not sole, treatment for those, like myself, suffering from ME. This in the teeth of a significant and growing body of research indicating that there is a serious physiological pathology underlying ME, not simply psychosomatic causes. I would be interested to know your thoughts (if any) given that the research on actual mental health issues throws doubt on the efficacy of a purely CBT approach.

Dugald, thank you for your reply to my blog. Would you please help me get the word out about the research by sharing the links with everyone and anyone who will listen. Limiting choice makes no empirical sense. It makes much more sense to ask professionals to measure outcome. Available evidence makes clear: all approaches can work. The question is: does it fit and work for the client.

Donald, I’m far from an expert in this area but I recommend you read a book called The Body Keeps the Score by Bessel van der Kolk. The brain/nervous system can wreak powerful physiological changes in he body separate to how the perception of bodily states may or may not be altered by mental/emotional distress.

Hello, I’ve had CBT, as it is one of only 2 treatments available in the UK for people with ME, the other being Graded Exercise Therapy. Both are useless for ME as it isn’t a mental health condition, but a physical one, but that’s all we have.
What the CBT did help me with was managing my emotions around coping with this hideous illness. There are strong links between ME and depression (go, figure) and I use what I’ve learnt to manage my mental health and stay mentally well.
There’s also some research showing CBT has become less effective over time in the UK.
People with mental I’ll health need lots of solutions, not a one size fits all approach.

Limiting available treatments makes no empirical sense. Thankfully, the system is paying more attention to consumer voices. PLEASE, don’t be silent. Write the papers, tell your friends, let people know that choice is important.

Thank you for sharing – an interesting article. Open and informed debate on the pros and cons of any evidence-based treatment should be encouraged, but the headline of the article is vastly misleading.

Equating the widespread use of CBT as a causal factor for the increase in the national prevalence of anxiety and depression is simply misinformed. Firstly, there are clearly various factors involved in any national level increase in prevalence of mental health conditions. For example, the provision of a national level program to increase community access to therapy would have a side effect of increasing client presentation to mental health clinics and therefore increase the number of diagnosed mental illnesses; similar effects have consistently been demonstrated around the world. Secondly, numerous empirical studies have demonstrated the effectiveness of CBT over and above placebo, medication, and alternate therapies for a range of mental health conditions. Of course, there are other treatments that outperform CBT by a great margin for some populations or presenting problems, but CBT is very useful for treating depression and anxiety in a range of populations. There are a number of other issues with making such a simplified conclusion as represented in the headline, which can lead to perpetuation of misinformation.

No one can claim that CBT is a panacea for all mental health problems, but it is a very useful and effective therapy in a range of contexts. Put simply, the available evidence base should be drawn upon to guide which treatments are utilised for which conditions and in which environments.

The Society for Exploration of Psychotherapy Integration (SEPI) was founded in 1983 and since then has devoted to exploring potential convergences and synergies between different approaches to psychotherapy and the different theoretical orientations from which those approaches derive. I was lucky enough to been educated in this approach and before graduated I was already aware that CBT didn’t work for every client and for every disorder. Since then, I had been called to think of each case in the following terms: (1) a theory of adaptation, (2) a theory of disorder, (3) a theory of intervention. This follows an integrative meta model called Paradigmatic Complementarity ( http://paradigmaticcomplementarity.weebly.com/ ).

Unfortunately, psychology field and psychotherapy seems divided about evidence based treatment for each disorder and difficulty. Moreover, governments should start recruiting independent consultants to use funding in a more effective way when it comes to the challenges of mental health.

However, studies are now concluding that CBT is not an exclusive and generalised answer to mental health.

Hi Scott and thanks for bringing this to our attention. I’ve always thought that the relationship between the client and therapist was of the utmost importance to produce improvement in symptoms. Trust is one aspect of this and another is respect. To some clients the implication that their thinking is faulty can be felt as deeply disrespectful.

Finally someone has stated the obvious. While I think CBT has it’s place, for the types of clients I see it is rarely my first choice. It seems to work best for those who symptoms are not a life long issue or hasn’t been in place since child hood. While I am CBT certified, I have always felt that this and some other approaches that claim in a very few sessions all will be well is hooey. As i said it has it’s place. But for life long issues my go to is Depth Therapy. I have had clients state to me that they felt like CBT was an insult to their intelligence. My clients report great success with Depth Therapy. Eight to ten sessions it is not.

I’m currently not in active practice but this just makes me glad to see another decent study like this. When I worked at a community mental health center, DBT was all the new buzz and my agency had pretty much decided that it was all that would be offered for groups regardless of whether the client wanted to attend. It was like the client wasn’t utilizing the sacred therapy so that was that. Back then I just wanted to say The DBT Emperor Has No Clothes On! To be fair, the agency gradually moved toward a wider offering of approaches for clients but I hate to think how many people got shamed needlessly. I don’t know current practices at the agency. Thank you Scott for sending out this latest information!

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